Where Health Reform, Medical Innovation, and Physician Practices Meet - The Leading Voice for Medical Innovation on the Internet

Thursday, June 30, 2016

Electronic Health Record Software Fatigue

Physicians are sick
and tired of electronic health records(EHRs).

Supposedly, doctors
are told, EHRs will.

·Reduce medical records.

·Narrow disparities in care delivery

·Engage patients in their own care.

·Spark coordination of care.

·Give access to best practice management.

·Enhance communication across the health care spectrum.

Instead, doctors
complain, EHRs;

·Aren’t ready for prime time.

·Slow productivity.

·Decrease revenues.

·Show no return on investment.

·Don’t communicate with other EHRs.

·Distract with time spend with patients.

·Are limited as communication tools.

·And are, many other ways, including expense of hiring and training staff to enter data and to code, a PITA
(Pain in the Ass).

Another Complaint

Now doctors have another
complaint -the number of alerts,
alarms, and reminders popping up on EHR screens are overwhelming and are resulting
in a bad case of “alert fatigue.

According toa June 15 story in Kaiser Health News “Screen Flashes and Pop-Up Reminders: Alert
Fatigue Spreads Though Medicine.”

“When physicians are hit with too much information, the result can
be a health hazard. The electronic patient records that the federal government
has been pushing — in an effort to coordinate health care and reduce mistakes —
come with a host of bells and whistles that may be doing the opposite in some
cases.”

“Electronic health records increasingly include automated alert systems
pegged to patients’ health information. One alert might signal that a drug being
prescribed could interact badly with other medications. Another might advise
the pharmacist about a patient’s drug allergy. But they could also simply note
each time that a patient is prescribed painkillers — useful to detect addiction
but irrelevant if, say, someone had a major surgery and is expected to need
such meds. Or they may highlight a potential health consequence relevant
to an elderly woman, although the patient at hand is a 20-something man.”

“The number of these pop-up messages has become unmanageable, doctors and
IT experts say, reflecting what many experts call excessive caution, and now
they are overwhelming practitioners.”

“ ‘Clinicians ignore safety notifications between 49 percent and 96 percent
of the time,’said Shobha Phansalkar, an assistant professor of medicine at
Harvard Medical School.’When providers are bombarded with warnings, they will
predictably miss important things,’ said David Bates, senior vice president at
Brigham and Women’s Hospital in Bosto

In any event physicians are responding to deluge of medical alerts and
alarms by simplyignoring and overriding
them most of the time.

As the old Aesop story went,when
the shepherd boy called “Wolf! Wolf!” too many times, when the wolf finally came, no one would pay any attention to his
calls for help.

Wednesday, June 29, 2016

HealthReform.com

The
utopium of the people.

Professor
Arthur Case (1894-1946), commenting on promises of welfare state

Health 2.0 is the premiere showcase
and catalyst for the advancement of new health technologies. Through a global
series of conferences, developer competitions, and leading market intelligence,
Health 2.0 drives the innovation and collaboration necessary to transform
health and health care.

Self-Definition, by Health 2.0

How have promises
of the health reform law and potentials of Internet applications impacted
patients and physicians at the site of care?
How have private sector efforts, as exemplified by the Health 2.0,
advanced health reform? Has the craze for more algorithms, guidelines, protocols, lists of tests doctors can and cannot do, pay for performance based on data gone awry or just contributed to more clinician hassles at the point of care? And has IT, as
far we know, lowered health costs, expanded access, and improved quality and
outcomes?

Health 2.0 and the Health Care Blog

Health 2.0 is a powerful and impressive movement
that considers itself “a leading showcase of cutting-edge innovation since
2007.”

Indeed it is.This fall Health 2.0, an Internet-related company, will stage its 10 annual
conference.It expects over 2000
participants.It was co-founded in 2007
by Matthew Holt.

Holt also co-founded The Health Care Blog in 2003. It has
50,000 to 150,000 readers each month.

Among these readers
are patients, caregivers, physicians, health information companies, and venture
capitalists. Its goals include deployment of data to judge the value of health
care, defined as outcome/price.

The Health Care Blog and Health 2.0 have been successful enterprises.Its founders recognized the Information Age
had arrived full force and would be vigorously applied to health care. Given the reality that the government-medical-industrial complex is a $300 billion industry, the prospects for IT applications to transform health care are limitless.

The world is moving fast on Internet time,
and an innovative private sector, in conjunction with government, had a powerful role to play.The
Obama administration acknowledged this reality as well,andled
to its belief that an interoperable, all-purpose, all-reaching, all-the-time
available, online system connecting all major health care players holds the key to improving access and quality of the
American healthsystem.

Health 2.0 personified concepts like collaboration, openness,
participation, and social networking.It is concerned with software licensing
and delivery and cloud-based technologies and their applications on multiple devices. Health 2.0 describes the integration of these into much
of general clinical and administrative workflow in health care. About 3,000 companies
offer with venture capital funding of over $ 2.5 billion.

A Technologically-Incorrect Mindset

But how has IT
technologies and their broad applications affected patients and physicians, who
are the key to any successful health reform?

As the author of
4350 Medinnovation and Health Reform
blogs since 2006 and three book Innovation-Driven Health Care (Jones and
Bartlett, 2007), Obama, Doctors, and
Health Reform (2009),and The Health Reform Maze (2011).I have reservations about the limits of the health care information revolution.

HealthReform 2.0 is another mindset. It is a loose term describing the
limitations of Internet applications and how humans react to the
cyber-revolution.

I accept
the power of the Net and its applications to shape and power of health reform, I am techno-skeptic. Data isn’t everything, it isn’t the only thing, it is one of many things, including skepticism
about total reliance on data as the main indicator of what constitutes a health
or a health-conscious society.

Internet-driven care may be oversold as a tool to improve health care,
implement reform, cut costs, and empower patients. Useful, yes, but over-hyped
as the Holy Grail, as the OSHA (Our Savior Has Arrived) of heath reform.

Taking a Step Back

The time has come to
step back, taking a deep breath, and to stop being breathless about the unlimited
prospects of cyber-apps as the principle agent and Holy Grail for transforming
health care.It is time for perspective
on the merits and shortfalls of web-driven information technologies.

Not Alone

I am not alone in
my skepticism about the limitations of health reform.

·In 2007
Jerome Groopman, MD, a Harvard oncologist,wrote in his bookHow Doctors Think, “A doctor can’t think with one eye on the clock and another on
the computer screen… a movement is afoot to based all treatment decisions
stt5icktly on statistically proven data.This so-called evidence based medicine is rapidly become the canon...
But today’s rigid reliance on evidence-based risks, having the doctor chooses
care passively, solely on the number isn't realistic. Statistics can’t substitute for the
human been before you; statistics embody averages, not individuals.”

·Robert Wachter, MD a West-Coast medical school
professor, explained in his book The
Digital Doctor: Hope, Hype, and Harm at the Dawn of the Computer Age (2015)
that electronic heath record use could bring harm... A 2013 study found that the electronic
health record was a dominant culprit in bringing harm. A 2013 study found that emergency
room doctors clicked a mouse 4,000 times during a 10-hour shift. Computer
systems, noted Wachter, "have become the dark force behind quality measures.”….evidence has mounted
that even superb and motivated professionals had come to believe that the
boatloads of measures, and the incentives to ‘look good, had led them to turn
away from the essence of their work.”

·Andrew
Keen, a denizen of Silicon Valley, executive
director of Silicon Valley's FutureCast, and a regular commentator on all
things digital, asserted in this book The
Internet Is Not The Answer (2015), that that data and it computer
applications,were oly part of the answer
for improving society, but they were not the total answer and were often
destructive in undermining our culture and our economy. He examined the dimensions of its worldwide networks, showed how had destroyed
many major industries, created a culture of personal narcissism, destroyed
personal privacy, and caused deepening economic and social inequalities.“Creative destruction” is part and parcel of
capitalism, but it has its downsides.

·In
2016,Andy Slavitt, acting CMS director,after he and his teaminterviewed thousands of physicians about their perception
of the utility of electronic health records saidhe believes that the measurement craze has
had its negatives. He said doctors feel all the data entry “took time away from
patients and provided nothing or little back in return. Physicians are baffled
by what feels like the ‘physician data paradox,’” he said. “They are overloaded
on data entry and yet rampantly under-informed.”But the rest of Slavitt’s
statement reveals he has no idea how to solve the “data paradox.” He asserted
that “technology that works for doctors and patients” is the ideal solution but
it offends many physicians.He added, “We
have to get the heart and minds of physicians back.I think we’ve lost them.”Because of widespread physician resistance, Slavitt announced the end “meaningful use” EHR
mandates.

·A study on electronic medical records use by the
California HealthCare Foundation, a philanthropic group, found that 15% of the
1,849 adults surveyed said they’d conceal information from a physician if “the
doctor had an electronic medical record system” that could share that information
with other groups. Another 33% would
“consider hiding information.” This is an example of the garbage in, garbage
out phenomenon when it comes to interpreting the reliability of algorithms to improve care.

Conclusion

The Internet Age is upon us, and it may well in the end transform the health system
for the betterment of all.Information
technologies have the potential of making health care more efficient and objective,
improving the health and extending longevity,identifying what is of value for each
dollar spent, decoding the genomic secrets of disease, and deciphering and streamlining the organizational
and disease complexities.

And yet, the Internet is no panacea, no cure-all for the
problems, costs, and complexities of health care that beset and befuddle humankind. Medicine and health care are fiendishly
complicated, and the Internet sometimes makes them more so.

The Internet often intrudes into patient-doctor relationships,
tends to decrease private and confidential relationships, and accumulating the
data that feeds its algorithms and helps it reach its conclusions pose
expensive, cumbersome, and distracting propositions for clinicians and patients
alike on the front lines of care.

One
last comment. The extensive use of electronic health records has contributed to
physician shortages, to physicians abandoning traditional practices to enter
concierge practices to escape coding and other 3rd party electronic
mandates, to physicians accepting fewer Medicare, Medicaid, and ObamaCare exchange patients, and to physician burnout.

According to Mayo Clinic studies, EHRs are the leading cause of
physician burnout, to wit, “Although electronic health records, electronic
prescribing, and computerized physician order entry have been touted as ways to
improve quality of car, these tools create clinical burden, cognitive burden,
frequent interruptions and distraction – all of which contribute to physician burnout):”Electronic
Tools Fan the Flames of Physician Burnout, “” Health Leaders Media, June 27, 2016).

In
a recent Washington Post article “Why Doctors Quit,” Doctor Charles
Krauthammer, psychiatrist, conservative commentator, and prominent health law
critic, after attending his 40th Harvard Medical School reunion, quotes one of
his classmates, “My colleagues who have already left practice all say they
still love patient care, being a doctor. They just couldn’t stand everything
else…. a never-ending attack on the profession from government, insurance
companies, and lawyers... progressively intrusive and usually unproductive rules
and regulations,” topped by an electronic health records (EHR) mandate that produces
nothing more than “billing and legal documents” — and degraded medicine.”

Sunday, June 26, 2016

Predicting
and Preventing Later Deathfrom
Cardiovascular Disease in Adolescents

This week an article in the New England Journal of Medicinecaught my eye: “Body-Mass Index
in 2.3 Million Adolescents and Cardiovascular Death in Adulthood.”The article groups data on BMI, as
measuredfrom 1967 to 2010 in 2.3 million
Israeli adolescents (mean age 17.3),and
correlatesthe number of deaths: 1497 from coronary artery disease,528 from stroke, and 893 from sudden
death.

Those in overweight and obese categories had an increased
hazard of dying suddenly or from coronary disease4.9 times,stroke 2.6 times , or sudden death2.1 times, than others in the 40 years of follow-up.

Why Not?

These results got me to thinking – Why not alert adolescents
to their risk of death using BMI data when all that is required is their weight
and height?Why not add to weight and
height data,BP levels, and certain lab
tests like glucose and blood lipid values?Why not accompany these data with document stating their relative health
and their cardiovascular risk?

Perhaps I was oversimplifying.But everybody knew, then and now, that obesity,high blood pressure,diabetes, and aberrant lipid valuesare reliableprognosticators of future fatal cardiovascular events.And these measurementsweight, height,blood glucose, and lipid values are easily
obtained during routine visits to a doctor.

Not
Optimistic

But I am not optimistic about the use of routine data
as a tool for preventing deaths or changing behavioral lifestyles

In the 1980s,I developed somethingcalled the “health quotient,”normal range 80 to 120,based on the BMI,blood pressure, and routine blood test values
for glucose and lipids.We measured
these things on thousands of patients, mostly non-adolescents,and sent results to the patients.We found roughly 30%-35% of government employeeswere pre-diabetic or diabetic, hypertensive, and had worrisome lipid
changesthat often precede heart attacks
or stroke or sudden death.

But to little avail.We learned patients were reluctant to acknowledge theirpresent and future health problems. to have their problemsdocumented as part of their official health
records,or to change their life styles;
employers were reluctant to pay for follow up studies;and physicians were reluctant to heed results
or to have the results imposed upon them when they had not specifically ordered.

For these and other reasons,I am reluctant tooverstress the
impact that predictive health data might have on the field of “population
health,” which is the rage right now in improving the overall health of
Americans. Culture and life style are difficult things to change, once they have
been imbedded in your environment and your approach to health.

“In 1997, Sebastian
Junger, an author and journalist, wrote the best seller, The Perfect Storm, later
a movie. The book told the story of fisherman off the New England Coast trapped
by three converging weather systems.Three Weather Systems

• Warm air from a low pressure system coming from one direction.

• Cool, dry air generated by a high pressure system coming from another
direction.

• Tropical moisture provided by Hurricane Grace.

An Analogy

This is a good analogy for today’s perfect p health reform storm.

• Warm air, suddenly heating up as evidenced by the midterm elections, from a
low pressure system coming from outside the Beltway, with conservative
Americans calling for smaller government, less interference in their lives,
lower taxes, less spending, less debt, and “taking our government back.”

• Cool, dry air provided by a high pressure, dispassionate, scientific,
management-oriented Washington insider elites speaking in cool, dry terms about
the need for a rational restructuring of the whole system from above.

• Tropical moisture (both sides claim the other side is all wet) producing a
hurricane of opinionated bilateral rhetoric speaking in apoplectic and
apocalyptic terms about the abyss that lies ahead if their respective opinions
do not prevail.

Caught in the Middle

Caught in the middle of this perfect reform storm are physicians and patients
who fear the worst, who feel they have no reform voice and no control over
impending colliding weather systems.

• On the one hand, American health consumers have high expectations,
fueled by the high tech performance of the current system, and the promise of a
new entitlement system providing more care at lower costs. They expect the best
medicine has to offer at more “affordable” price. These twin expectations are
central elements of the perfect storm.

• On the other hand, a centralized government is saying the whole system
must be overhauled and restructured, and physicians must offer less costly care
under a system of expensive regulations with which they must comply at lower
reimbursement rates without protection from tort reform.

• On the third hand, sometimes called the third or the center-right way,
there may be a middle way out the storm, through disruptive innovations using
cheaper care at decentralized locations, like the home, provided by less
sophisticated personnel using electronic , and downsizing of the whole medical
enterprise.

Time Not on Side of Those in The Boat

The problem with all of these scenarios is that with an imminent perfect storm,
time is not on your side, the reckoning is at hand, and physicians in the boat
with patients, must cope with the consequences – the impact of the perfect
storm on their professional and personal lives.”

Today’sPolitical Storm

Which leads to the
present blog.The health reform storm
I described6 years ago now
involves3 world-wide weather
systemscolliding with one another.

Firstare forces of globalization, standardization,
and socialism.These
forces call for international economic integration,top—
down remote political organizations dedicated to leveling and closing economic gaps between nations,all acting together in harmony tocombat climate change, and to promote immigrations across nations without borders- all led by
experts and elites and bureaucrats using information from cyberspaceand deploying algorithms to elucidate and to crystallize complexities to make the world
more efficient, rational, and equal. The
elites, the young,the well-educated, and
the IT-skilled tend to belong to this movement.

Second
are forces of nationalism and cultural
preservation. These forces, sometimes marching under the banner of populism.
maintain globalization has not delivered on its promises , is destroying national
identities,is stifling innovation and
business with bureaucratic shackles, is ignoring common workersand the middle class while feathering nests of the elite, does not meet the needs and destroys the
traditional life styles of common folks andhas
little ideahow the real world works,
and fail to realize mass integration changes their ways of life.Older
people, those left out by globalization, automation,IT-displacement belong to this school.

Third
are forces of economic reality. These
forces say there is something badly wrongwith current forces and trends ,which haveproduceddeep unemployment , massive migrations, a world-wide recession from which the West has
yet to emerge,political
instability and uncertainty, and rise of
terrorism.Something profound, even
revolutionary,has to happen. This change can no longer be ignored or placed
in the hands of traditional elites, who say the answer lies in patience with the status quo andincremental progressivism.Hence the rise of Trump,Brexit,populist movements in Europe,socialism among the young,and the call for a radical change of direction.The political question is: Has the time come for fundamental change, or should it be steady as she goes with incremental fixes at the edge?

Saturday, June 25, 2016

You can call sovereignty other things as well -autonomy, self-governance, self-rule,
self-determination,freedom, desire for privacy, rise of populism,revolt against powerful elites and remote bureaucracies,resurgent nationalism,and power to control one’s destiny on
one’sown terms.

The
Brexit Example

Whatever name you wish to use, sovereignty is significantly politically , as evidenced by Britain’svote to exit from the European Union, a revolt
against being told what to do by faceless European bureaucrats in Brussels. Fraser Nelson , editor of the Spectator and columnist for the Daily
Telegraph,said Brexit was similar to
other battles being fought in Western democracies, “It is the jet-set graduates versus the
working class, the metropolitans versus the bumpkins – and, above all, the
winners of the globalization against the losers." It is a cry for liberty by workers suffering from economic stagnation and a rebuke of the political elite establishment.

The
American Counterpart

Sovereignty is important in America as well. It is the will
of the people, asthey revolt against the establishment in
Washington, D.C.,and against being “globalized”
as a forgotten subsidiary of the world’s global economy.Global climate warming agreements,international trading pacts, secretive foreign treaties
with adversaries, and withdrawal of American power from the world scene, may be
the ways to go, but the opposition do not agree. As in Britain, middle class and worker anger is growing as is reaction against immigration, globalization, free trade, unemployment, capital flight, and the technology elite, rich people, and the well-educated.

Sovereignty
in Health Care

In American health care,sovereignty manifests itselfas a
reaction against ObamaCare.The basic thrust of the health law is having
Washington “govern” the patient-doctor relationship. This is done in the names
of enhanced efficiency, quality, and outcome, as seen through the eyes of
governing elites.

Gains
and Losses

Among patients and physicians,thisgain in government power is perceived as loss of personal sovereignty. It comes at a price – higher taxes,more regulations,loss
of privacy, and increased intervention
into the lives of patients and disruption of physician work patterns.

Patients and doctors resent having their life styles and
practices measured,monitored,and transformed and being told what to do.

That is why as many of one-third to one-half of patients withholdor distort information or even liewhen they see doctors using electronic health record systems to record
their personal information.

That is why physicians complain about government-induced
hassles, leading to losses of productivity,overhead expenses, and time spent away from patients – all to please the
whims and misconceptionsof
governmentbureaucrats and policy elites.

It may be, of course, that each mindset – that of the government
elite and that the governed -are partly right and partly wrong.

Culture-Changing
Events

Whatever point of view prevails , keep in mind that cultural changing events -interconnected information-globalization
produced by computerization,universal
access to this information by IPhone and other devices, mass
migration facilitated by open-border mentalities,declinesin the personal and physician
sovereignties ,and noble bureaucratic intentions
to improve population-healththrough use
of data -come at a high price, will generate controversies about loss of personal “liberties and freedoms, “ and will take time to implement and cultural attitudes
to overcome.

Thursday, June 23, 2016

House Republicans just released a 37 page health plan ofnhow
they propose to replace ObamaCare.

The document contains these key
points.

It would:

·Repeal ObamaCare but retain 3 of its provisions – 1)
coverage of young adults under their parents’ plans, 2) those with pre-existing conditions, and 3, not
allowcancellation of policies
because of disease.

·Expand Health Savings Accounts allowing people to
use tax-free money to pay for care.

As expected, the plan was met
with mixed review.Republicans insisted
the plan was “patient-centric” and "market-based" and would lower premiums,decrease costs,and expand access and choice.Democrats said it was vague, non-specific ,
would tax workers’ benefits, consisted of recycled ,stale GOP ideas of the past,and said nothing of how to covered the 20
million newly insured and subsidizedby
ObamaCare.

Here, briefly, is what the media said about the plan.

·The New York Times said it was full of vague unsubstantiated chatter.

·Kaiser Health News stressed its emphasis on “high
risk pools,reliance on state-controlled
funding of Medicaid,and that it left
alot of questions unanswered.

·The Atlantic commented it showed a recommitment by the GOP
to repeal Obamacare and to reform Medicaid and Medicare.

·Investor’s Business Daily hailed it as step towards a market-based
system that would remove the “heavy hand” of government.

·The Wall Street Journal said it left too many details to be filled
in,and depended on Trump’s election,
but as least it gave the GOP an agenda to run on.

·The Los Angeles Times ridiculed it as “Ryan’s plan” and reinforced the
notion that the GOP was not really serious in tackling complex health reform
issues.

·Politico said it “was short on details”
on how the GOP proposed to reduce premiums by double digits. bend the cost
curve downward, cover those recently subsidized by ObamaCare

·Bloomberg summed it up by saying it would
end ObamaCare while keeping its most popular parts.

One leading Republican said the
37 page plan was simply a “framework for debate” and depended on which
political party emerged “triumphant”, perhaps “Trumphant”is a better word,in the 2016 general election. The
ultimate question, of course, is : Who shall
control the rules and expenditures for health care, centralized government or diverse markets, and in what proportion?

The Health Reform Maze

Buy the Book

Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.